THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. EVERGREEN SOLUTIONS, LLC'S PLEDGE TO PROTECT YOUR HEALTH INFORMATION:
Evergreen Solutions, LLC (the "Agency") is committed to protecting information about you and your health record. Your provider will create a record of the care and services you receive from them. The Agency needs this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all the records of your care generated by this mental health care practice. This Notice will tell you about the ways in which the Agency may use and disclose health information about you. This Notice also describes your rights to the health information the Agency keeps about you and describes certain obligations the Agency has regarding the use and disclosure of your health information. This Agency is required by law to:
1. Make sure that protected health information (“PHI”) that identifies you is kept private.
2. Give you this notice of the Agency's legal duties and privacy practices with respect to health information.
3. Follow the terms of the notice that is currently in effect.
4. The Agency may change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW EVERGREEN SOLUTIONS, LLC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that the Agency will use and disclose health information. For each category of uses or disclosures this Notice will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories:
1. The following categories describe different ways that the Agency will use and disclose health information. For each category of uses or disclosures this Notice will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.
2. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
3. Lawsuits and Disputes: If you are involved in a lawsuit, the Agency may disclose health information in response to a court or administrative order. The Agency may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. The Agency completes “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For your provider's use in treating you.
b. For your provider's use in training or supervising mental health other practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For your provider's use in defending themselves in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate the Agency's compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Marketing. Evergreen Solutions, LLC and its providers will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. Evergreen Solutions, LLC and its providers will not sell your PHI.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, the Agency can use and disclose your PHI without your Authorization for the following reasons:
1. Public Health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
2. Required by the Secretary of Health and Human Services: The Agency may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine compliance with the requirements of the final rule on Standards of Privacy of Individually Identifiable Health Information.
3. Health Oversite: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, and other government regulatory programs, and civil rights laws.
4. Serious Threat to Health or Safety: To prevent a serious and imminent threat.
5. Abuse or Neglect: To report abuse, neglect, or domestic violence.
6. Required by law: To comply with federal, state, and local law, law enforcement, and other government requests.
7. Judicial and Administrative Proceedings: To respond to a court order, subpoena, or discovery request.
8. Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
9. National Security and Intelligence Activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
10. Workers' Compensation: To comply with workers' compensation laws and support claims.
11. Coroners and Medical Examiners: Tor perform their legally authorized duties.
12. Research: For research that has been approved by an institutional review board.
13. Business Associates: To organizations that perform functions, activities, or services on the Agency's behalf.
14. Reminders: To contact you to remind you that you have an appointment with the Agency.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1. To your family, friends, or others if PHI directly relates to that person's involvement in your care.
2. If it is in your best interest because you are unable to state your preference.
VI. YOUR RIGHTS
1. To Inspect and Obtain Copies of Your PHI: You can ask for an electronic or paper copy of PHI. The Agency may charge you a reasonable fee. The Agency may deny your request if it believes the disclosure will endanger your life or another person's life. You have a right to have this decision reviewed.
2. To Amend Your PHI: You can ask to correct PHI you believe to be incorrect or incomplete. The Agency may require you to make your request in writing and provide a reason for the request. The Agency may deny your request. The Agency will send a written explanation for the denial and allow you to submit a written statement of disagreement.
3. To Request Confidential Communications: You can ask the Agency to contact you in a specific way. The Agency will say "yes" to all reasonable requests.
4. To Limit What is Used or Shared: You can ask the Agency not to use or share PHI for treatment, payment, or business operations. The Agency is not required to agree if it would affect your care. If you pay for a service of health care item out-of-pocket in full, you can ask the Agency not to share PHI with your health insurer. You can ask the Agency not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.
5. To Obtain a List of Those with Whom Your PHI Has Been Shared: You can ask for a list, referred to as an "accounting," of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for an accounting more frequently.
6. To Receive a Copy of This Notice: You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.
7. To Choose Someone to Act for You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
8. To File a Complaint: You can file a complaint by contacting the Agency using the following information:
Lauren Holloway at Evergreen Solutions, LLC
2222 W. Grand River Ave, STE A
Okemos, MI. 48864-1604
(906) 205-5275
You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, S. W., Washington, D.C. 20201; calling 1-877-696-6775; or visiting www.hhs.gov/privacy/hipaa/complaints/.
The Agency will not retaliate against you for filing a complaint.
THIS NOTICE IS EFFECTIVE BEGINNING 09/09/2024
We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.
